Women's Care Center of the Heartland
2301 South 15 Street, Omaha, NE 68108 (402) 502-9224


Dear potential resident

   Thank you for contacting us. An application form is enclosed. When we get to meet, I will give you a resident handbook that hopefully you will read. Of course, we do have a structured environment and encourage our residents to be working on education or continuing on a job if they have one.

   We include the program on Healing the Culture (The 4 Levels of Happiness) and Earn While You Learn (a parenting program). We are adapting our programs and policies from other maternity homes and are adjusting them as needed.

   Many businesses and volunteers have done much to make sure the building is comfortable and home-like. We will do our best to help each resident adjust and find a path in life that suits her. There are many community resources we can utilize. One of the first items of importance is to get you on housing lists. We utilize professional pregnancy counselors from several agencies to help sort through the many decisions each mom will encounter. The avenues of parenting and adoption will be presented but the decision is solely that of the mother.

   Although we are Catholic based, we welcome women from any or no religion. I briefly explain our traditions and encourage all our residents to be involved in religious services somewhere each weekend.

   I look forward to meeting you. When the application is returned, I will send you a questionnaire and a separate one to each of the three references that you list. We do ask for a $350 damage deposit that will be returned when you finish the program and leave - around 6 weeks after the birth of your baby. However, if there is financial difficulty, we can work around it.

Praying for you

Carolyn LaGreca
Executive Director

WOMEN'S CARE CENTER OF THE HEARTLAND

RESIDENT APPLICATION


PERSONAL
Name:_________________________________________________________________________Date:______________ 			

Current Address:_________________________________________________________________________________ 											

Birth date:_______Phone:_______________________________ Social Security No.:_____________________				

Department of Public Assistance ("DPA") Caseworker:______________________________________________ 							

DPA Number:_______________Phone No:_______________________ 				

Do you have any other caseworker or counselor?_________If so, list:______________________________

Name:____________________Agency:_________________________________________________________________ 				

Address:_________________________________________________________________________________________ 								

Current Income: $________________ mo.____________Source:_________________________________________ 					

Do you have any physical or medical conditions that limit your activities?______Yes_____No If so,
 specify:





What are your favorite activities or hobbies?





EDUCATION/VOCATION
Present or last high school attended:____________________________________________________________ 								

Address:_________________________________________________________________________________________ 												

Dates attended:_________________________________________ Last grade completed:___________________ 			

If you have dropped out of school:
Age when you left:___________				Last grade completed: ___________________			

Reason for dropping out: ________________________________________________________________________										

Have you received any schooling other than high school? ________ Yes ___________ No

If so, name of institution:______________________________________________________________________ 					

Course of study: ______________________________Dates attended:___________________________ 				

YOUR LIVING SITUATION
List the people currently living in your household: 																				
Persons you have been living with if other than your parents: 
Name: _________________________________________________	Phone: __________________________________				
Address: 												


PARENTS
Father's name: ________________________________ Mother's Name: __________________________________				

Address: ______________________________________ Address: ________________________________________					

Phone:  Home (_____)___________________________	Phone: Home (____) ______________________________			

Work: _________________________________________ Work:____________________________________________ 						

Employer:______________________________________	Employer: _______________________________________ 					

Are your natural parents (check appropriate box):
_____ married and living together	_____ separated	_____ married not living together
_____ divorced	_____ deceased (which parent? ____________________)

If your natural parents are not living together, how long have they been apart?__________________

Have either of your parents:	_____ remarried? (complete below)
_____ lived with another partner?

Stepfather's name: _____________________________________________________
											
Stepmother's name: _____________________________________________________ 											
 
BROTHERS AND SISTERS (including step and half)

Name			Age	Sex	Address
			
___________________________________________________________________________________________________

___________________________________________________________________________________________________		
			
___________________________________________________________________________________________________
			
___________________________________________________________________________________________________			

What are you doing now? ____ school ____ training program ____ job _____ other (specify)

Name of school or employer: _______________________________________________________________________									

Address: __________________________________________________________________________________________ 												

Course of study or position: ______________________________________________________________________ 										

Do you plan to continue your education or receive any more training at the present time?
	________ yes		________ no			________ don't know

I plan to study __________________________________________ at ____________________________________ 						

What is your educational goal?



What is your vocational goal?


YOUR CHILD(REN) (Fill out only if applicable)
Name: _________________________________________________________	Birth date: 				

Social Security No.: __________________________________________	DPA No. __________________________ 				

CHILD CARE

Who will be caring for your child(ren) while you are a resident at WCCH?

Name: 	 Phone: 			
Address: 					
__________________________________________________________________________________________________

RELIGIOUS BACKGROUND
From what religious background do you come?_______________________________________________________ 							

Are you currently attending church? _____ Yes _____ No

What is the name of the church? __________________________________________________________________ 									

If you are not currently attending church, what religious or denominational preference
would you have?





Why are you interested in moving into our household?




How did you find out about our program?




What things about yourself do you want to change or improve?




Do you realize this will be a structured environment including educational, parenting, and 
Life skills goals?    
			_______Yes  _______NO



_____________________________________________
Applicant Signature



Dated: ________________________________________

 
REFERENCES

List three people who know you well. You may name one relative. Please include your social worker
or school counselor if they have worked with you in the past two years. Give complete mailing 
addresses.

1.	Name:______________________________________	Phone: _______________

	Address:_____________________________________________________________

	City, State, Zip:________________________________________________________

	How do you know them?






2.	Name:______________________________________	Phone: _______________

	Address: _____________________________________________________________

	City, State, Zip: _______________________________________________________

	How do you know them?






3.	Name: _____________________________________	Phone: ________________

	Address: ______________________________________________________________

	City, State, Zip: _________________________________________________________

	How do you know them?














WOMEN'S CARE CENTER OF THE HEARTLAND

RESIDENT APPLICANT QUESTIONNAIRE



Your name:________________________________________________________________Age:_________ 		

Your Child(ren) name(s) and age(s): ___________________________________________________________

_______________________________________________________________________________________________

Current address where you receive mail:

Street or box number:_____________________________________________________________________
 										
City___________________________ State:_________Zip:________________
 			
Phone number where you can-be reached during the day: (	  ) _____________________					

FAMILY

Please write a paragraph concerning your relationship with your parents.






Please write a paragraph concerning your relationship with your brothers and sisters.






CHILD'S FATHER
Please give the full name and the age of the father of the baby:





How did he feel about the pregnancy and what are his feelings now?




What is your relationship with him at the present time?




Does he know you are thinking about coming to our home? 		Yes  		No



RELIGIOUS
How active have you been in church, if at all ? What are your general feelings about religion
and God? Please write a paragraph.








MEDICAL
Please list any previous pregnancies and describe what happened: Include the due date and, 
if you had an abortion, when that occurred.






Please give a list of all the drugs you have used, how often you used them and the last time 
that you had them.





Why did you decide to try to take drugs? If you have quit taking them, why did you decide to stop?






 
Please write a paragraph about your use of alcohol. Include how often you drank and the last time 
you had a drink.






When you drink, do you drink to get drunk and if so, why?





What made you decide to use alcohol? If you have quit using alcohol, what made you decide to quit?






Why do you want to come here ?





What are some things about yourself that you would like to change or improve?





What are some goals you have for yourself and your child?


1._______________________________________________________________________________________


2._______________________________________________________________________________________


3._______________________________________________________________________________________


4._______________________________________________________________________________________





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